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Several common beliefs about osteoarthritis held by people living with the condition and some clinicians are discordant with current evidence and can hinder effective management. Therefore, providing information about the disease and its mechanisms could lead to better management of people with osteoarthritis. This paper addresses the seven most common myths surrounding osteoarthritis relating to its causative factors, pathology, assessment and management. We present the evidence to refute these misconceptions and argue that physiotherapists are in an ideal position to provide education to people with osteoarthritis. Ultimately, physiotherapists can play a central role in the provision of care for people with osteoarthritis.
Time to bust common osteoarthritis myths
Senior Lecturer, Physiotherapy Department, School of Clinical Sciences, Auckland University of Technology, Auckland, New Zealand
Senior Lecturer, School of Physiotherapy, University of Otago, Dunedin, New Zealand
Post-Doctoral Fellow, School of Clinical Sciences, Auckland University of Technology, Auckland, New Zealand
Head of School, School of Clinical Sciences, Auckland University of Technology, Auckland, New Zealand
Several common beliefs about osteoarthritis held by people living with the condition and some clinicians are discordant with
current evidence and can hinder effective management. Therefore, providing information about the disease and its mechanisms
could lead to better management of people with osteoarthritis. This paper addresses the seven most common myths surrounding
osteoarthritis relating to its causative factors, pathology, assessment and management. We present the evidence to refute these
misconceptions and argue that physiotherapists are in an ideal position to provide education to people with osteoarthritis. Ultimately,
physiotherapists can play a central role in the provision of care for people with osteoarthritis.
O’Brien, D. W., Chapple, C. M., Baldwin, J. N., & Larmer, P. J. (2019). Time to bust common osteoarthritis myths. New
Zealand Journal of Physiotherapy, 47(1), 18-24.
Key Words: Osteoarthritis, Beliefs, Attitudes, Treatment, Misconceptions
Osteoarthritis is the most common form of arthritis and,
typically, affects the joints of the knees, hips, spine and hands
(Hochberg, Silman, Smolen, Weinblatt, & Weisman, 2015;
Palazzo, Nguyen, Lefevre-Colau, Rannou, & Poiraudeau, 2016).
People with osteoarthritis often experience pain, joint stiffness
and weakness; this can affect their mobility, function, ability to
work, mental well-being and independence (Hall et al., 2008;
Hawker et al., 2010, 2011). Approximately 670,000 New
Zealanders live with some form of arthritis, of which 56% of
these people have osteoarthritis. Furthermore, prevalence is
expected to reach 1 million by 2040 due to projected increases
in the age of the population and the growing obesity rate,
factors known to affect the development of osteoarthritis
(Access Economics, 2018; Cross et al., 2014; Palazzo et al.,
2016). The total estimated cost of arthritis in New Zealand is
$12.2 billion per year, including $993 million in health sector
costs, $1.2 billion in lost productivity and $1.6 billion in formal
and informal care (Access Economics, 2018).
There is currently no cure for osteoarthritis, and unlike other
forms of arthritis, there are no disease-modifying drugs with
proven efcacy available for the condition. The focus of recent
research has been on the maintenance of physical function,
symptom reduction and limiting disease progression (Hochberg
et al., 2015). Exhausting all conservative treatment options is
encouraged before more invasive interventions are employed
(Hunter, 2017; Van Manen, Nace, & Mont, 2012; Zhang et al.,
2008). Current clinical guidelines recommend the use of non-
pharmacological treatments, such as lifestyle change, weight
loss, exercise and manual therapy (non-pharmacological), before
considering medication or surgery (Bennell, 2013; Bennell &
Hinman, 2011; Dean & Gormsen Hansen, 2012; Fransen et
al., 2015; Merashly & Uthman, 2012; Van Manen et al., 2012;
Zhang et al., 2008). The National Institute for Health and Care
Excellence (NICE) Osteoarthritis Guidelines (2014) advocate for a
staged progressive model of clinical management, which shows
a progression from non-pharmacological to pharmacological
to surgical management of osteoarthritis. However, non-
pharmacological treatments are underutilised, and while failed
conservative management is a prerequisite for surgery, some
people are offered joint replacement surgery without having
completed appropriate conservative management (Brand et
al., 2014; Hunter, 2011; Hunter & Lo, 2009). The continued
focus by some clinicians on the provision of pharmaceutical and
surgical treatment options has prompted some researchers to
publish editorials arguing that most people with hip and knee
osteoarthritis in high-income countries receive substandard
care (Hunter, 2011, 2017; Hunter & Lo, 2009; Hunter, Neogi,
& Hochberg, 2011). Additionally, it has been suggested that
some clinicians are guilty of benign neglect because they take
a fatalistic view of osteoarthritis or see conservative treatment
as ineffective or too complicated for their patients (Brand et al.,
2014; Poitras et al., 2010).
Despite the considerable amount of research detailing best
practice management for osteoarthritis, many high-income
countries, including New Zealand, have been slow to adopt
these recommendations (Baldwin, Briggs, Bagg, & Larmer, 2017;
Bennell, Dobson, & Hinman, 2014; Hunter, 2017). This delay
has been attributed, in part, to some of the common myths
about the disease (Hunter, 2017). In particular, myths about
causative factors, the pathology, assessment and management
of osteoarthritis abound. This paper aims to challenge the
myths commonly attributed to osteoarthritis that limit effective
treatment; outline best clinical practice; and encourage
physiotherapists to engage with people with osteoarthritis.
Myth 1: Osteoarthritis is just an old person’s disease
It is true that the likelihood of having osteoarthritis increases
with age, but it is incorrect to claim that it is an “old person’s
disease” as hip and knee osteoarthritis can also affect younger
people (Ackerman, Kemp, Crossley, Culvenor, & Hinman, 2017).
Ackerman et al. (2015) demonstrated the considerable personal
burden experienced by younger people (20 to 55 years) with
lower limb osteoarthritis, and recommended the provision of
targeted services for people in this age group. Furthermore,
younger aged people warrant additional attention to reduce the
development of comorbidities which may further compromise
their well-being (Skou, Pedersen, Abbott, Patterson, & Barton,
2018). Hence, it is false to solely attribute the development of
the disease to increasing age as its aetiology is multi-factorial
(Hochberg et al., 2015). The exact association between
osteoarthritis and increasing age is complex and not currently
fully comprehended (Hochberg et al., 2015). Increasing age
can lead to thinning and fracture of the cartilage covering the
articular surfaces of the joints. These changes can result in joint
laxity, predisposing the joint to increased shear stresses and
injury, promoting progression of the disease (Cross et al., 2014;
Hochberg et al., 2015).
However, many factors other than age are associated with
an increased chance of developing osteoarthritis. These
include gender, obesity, genetics, joint structure, a history of
injury and occupation (Palazzo et al., 2016). Osteoarthritis is
characteristically more prevalent in women than men, with
an odds ratio of 1.6 (95% condence interval [CI] 1.4-2.1)
(Silverwood et al., 2015). The reason for this is linked to
differences in hormones, joint alignment, cartilage volume
and muscle strength (Cross et al., 2014). People who are
obese are 2.7 times more likely (95% CI 2.2-3.3) to have knee
osteoarthritis than people who are not obese (Silverwood et al.,
2015). Increased body weight is believed to cause additional
joint loading and damage (Bliddal, Leeds, & Christensen, 2014)
as well as to contribute to systemic inammation (Piva et al.,
2015). Previous hip or knee joint injury is strongly associated
with the development of osteoarthritis (Hochberg et al., 2015).
Rupture of the anterior cruciate ligament predictably leads
to the development of knee osteoarthritis in 13% of people
within 10 to 15 years of the injury, and this rate increases
to between 20 and 40% if the injury also includes damage
to other ligaments, bone or cartilage (Palazzo et al., 2016).
Poor joint alignment is associated with the development of
osteoarthritis and more strongly associated with progression
of the disease (Cerejo et al., 2002; Sharma et al., 2010). In the
hip, joint dysplasia can commonly lead to the early development
of osteoarthritic changes (Jacobsen & Sonne-Holm, 2005).
Additionally, excessive occupational loads have been linked
to increased risk of disease development, especially if the job
or occupation requires a lot of kneeling, squatting, lifting or
climbing (Palmer, 2012).
Practice point myth 1: Osteoarthritis can affect younger people
and should be considered as a provisional diagnosis where there
are appropriate signs and symptoms.
Myth 2: Osteoarthritis is just joint wear and tear
Osteoarthritis is commonly typied by structural cartilage
changes. However, there are also changes in the muscles,
bone and synovial tissue at the joint. Hence, it may be best to
conceptualise osteoarthritis as a syndrome or a collection of
signs and symptoms. The pathology of osteoarthritis is multi-
faceted, and many different factors contribute to the joint
degeneration that occurs (Dell’Isola, Allan, Smith, Marreiros,
& Steultjens, 2016). These include biomechanical overload,
structural changes of the cartilage, metabolic mechanisms,
inammatory processes and genetic traits. While mechanical
factors are known to be necessary for the development of
osteoarthritis, it is still unclear what role the other factors
play (Hochberg et al., 2015). Osteoarthritis is known to be a
metabolically active disease, and changes can also occur within
the peripheral and central nervous systems, which may explain
non-mechanical pain symptoms described by some people with
osteoarthritis (Cruz-Almeida et al., 2013; Mease, Hanna, Frakes,
& Altman, 2011; Mills, Hübscher, O’Leary, & Moloney, 2019;
Skou et al., 2018).
In contrast to the notion that the joint is wearing out,
moderate levels of physical activity and exercise are believed
to be protective against the development of hip and knee
osteoarthritis (Bennell & Hinman, 2011; Fransen et al., 2015;
Skou et al., 2018). Normally functioning muscles have a
protective effect on joints as they distribute load across the
joint and help to maintain postural alignment (Bennell, Wrigley,
Hunt, Lim, & Hinman, 2013). Furthermore, there is a plethora
of studies demonstrating that improving muscle function with
exercise can reduce pain and improve function for people with
hip and knee osteoarthritis (Fransen et al., 2015; Hochberg et
al., 2012; Hunter & Lo, 2009; Loew et al., 2012; Skou et al.,
2018). Conversely, weak muscles at or around joints can lead
to the development of osteoarthritis due to a higher chance of
injury and altered load management (Hochberg et al., 2015).
Practice point myth 2: Osteoarthritis is not “just” joint wear and
tear. The disease is better conceptualised as a syndrome that
includes joint wear and failed repair. Hence, it is essential to
avoid describing or referring to osteoarthritis as “wear and tear”
when speaking with patients.
Myth 3: The worse the imaging looks, the worse the
joint is
Imaging, such as radiographs and magnetic resonance imaging
(MRI), is a standard tool used to diagnose osteoarthritis.
However, only half of the people with radiographic osteoarthritis
(visible x-ray changes) have clinical symptoms (Jordan et al.,
2007; Phan et al., 2005). As such, the assessment of a person’s
signs and symptoms may be more clinically relevant than the
imaging ndings. Furthermore, clinical guidelines suggest that
requesting an x-ray is not required to make the diagnosis of
osteoarthritis and is potentially problematic as it reinforces a
mechanical view of the disease (Bennell, 2013; Hunter, 2017;
McAlindon et al., 2014; National Institute for Health and Care
Excellence, 2015). In most cases, the diagnosis of hip or knee
joint osteoarthritis can be made by considering the signs and
symptoms that a person presents with (Hochberg et al., 2015).
Imaging should only be considered when appraising a person’s
appropriateness for surgery or when ruling out other potential
Practice point myth 3: Consider the additional merit of imaging
carefully. Radiographic changes can correlate poorly with
symptoms and lead to unnecessary interventions. Take care
when describing imaging ndings to people with osteoarthritis.
For example, avoid using terminology such as “degeneration”
or “bone on bone” that may incite fear-avoidance behaviours or
the belief that nothing can be done to manage the symptoms of
Myth 4: Osteoarthritis is the non-inammatory arthritis
Osteoarthritis was traditionally considered to be non-
inammatory arthritis, but the presence of inammatory
processes are now acknowledged (Berenbaum, 2013). Synovial
tissue inammation is believed to be one of the key intraarticular
processes that contributes to nociception and the subsequent
pain experience, with the inammatory changes leading to
intraarticular swelling (Felson et al., 2016). Moreover, extra-
articular structures can also become inamed and contribute
to the generation of nociceptive input (Hochberg et al., 2015).
Low-grade chronic inammation may be a consequence of
knee injury, or induced by metabolic syndrome or inammaging
(age-associated inammation), all of which are known risk
factors for the development of knee osteoarthritis (Berenbaum,
2013). Recent research has suggested a relationship between
osteoarthritis and metabolic disorders (Da Costa et al.,
2012; Mills et al., 2019). While the exact link is not yet fully
understood, a high body mass index and cardiometabolic
disease are associated with systemic inammation, and it
is this systemic inammation which is thought to inuence
osteoarthritis (Mills et al., 2019). Some researchers have argued
that metabolic-osteoarthritis should be described as a distinct
category or phenotype of osteoarthritis (Dell’Isola et al., 2016;
Deveza et al., 2017). Of note is that exercise is known to reduce
systemic inammation, which may explain why physical activity
positively affects pain and function for people with osteoarthritis
(Skou et al., 2018).
Practice point myth 4: Exercise can be benecial in reducing
inammation for people with osteoarthritis, and physiotherapists
can play a key role in prescribing exercise programmes.
Additionally, physiotherapists should consider engaging the
patient’s general practitioner for an analgesic review when
medication is considered appropriate.
Myth 5: Conservative treatments are ineffectual and only
designed to delay joint replacement surgery
Education, lifestyle and dietary changes, and exercise are the
cornerstone of management for people with osteoarthritis
(Bennell, 2013; Fransen et al., 2015; Hochberg et al., 2015;
Hunter & Lo, 2009). The focus of treatment for a person
with osteoarthritis should be on the maintenance of physical
function, modication of symptoms and limiting disease
progression (Fransen et al., 2015; Hochberg et al., 2015).
Treatment options should be employed progressively, starting
with more conservative treatments (exercise, weight loss,
education), and then progressing to pharmacological and more
invasive interventions (medication, surgery) as needed, while
incorporating patient preferences (Fransen et al., 2015; Larmer,
Reay, Aubert, & Kersten, 2014; National Institue for Health
and Care Excellence, 2015). In particular, there is abundant
high-quality evidence supporting exercise-based treatments
for people with hip and knee osteoarthritis (Bennell & Hinman,
2011; Fransen et al., 2015). Research shows that exercise
can positively inuence pain, muscle function, body weight,
cardiovascular tness, mood and disease progression (Bartholdy
et al., 2017; Bennell et al., 2014; Fransen et al., 2015; Kujala,
2009; Zhang et al., 2008), regardless of the structural changes
and symptom severity. The addition of joint mobilisation and
manipulation to exercise programmes may also be benecial
(Fitzgerald et al., 2016; Pinto et al., 2013).
Two of the biggest limitations to the efcacy of exercise-based
treatment are prescription and patient adherence. Poor exercise
prescription for people with knee osteoarthritis can result in
either overloading the affected joint, leading to increases in
pain and swelling; or more commonly, prescribed exercises
that are not challenging enough to facilitate a training effect
(Brosseau et al., 2016; Fransen et al., 2015; Hunter, 2017).
The inclusion of strategies to improve the adherence to the
prescribed exercises could boost treatment effectiveness (Bennell
et al., 2014; O’Brien, Bassett, & McNair, 2013). Physiotherapists
should consider employing strategies that assist people to begin
and sustain new behaviours that improve their osteoarthritis
(Bassett, 2015). Furthermore, as osteoarthritis is a chronic
disease, treatment should be viewed as a continuum of care;
hence, booster sessions should be considered to assist in the
maintenance of regular exercise (Brand, Ackerman, Bohensky, &
Bennell, 2013; Rosemann, Laux, Szecsenyi, & Grol, 2008).
Practice points myth 5: Exercise, education and weight loss
(where appropriate) are essential interventions for all people
with osteoarthritis, regardless of disease progression or symptom
severity. Prescribed exercises or physical activity programmes
should be collaboratively designed, should challenge the patient
and promote a training response, and should incorporate
strategies to enhance adherence. Joint mobilisation may also be
benecial if clinically indicated.
Myth 6: Discussing weight loss with people with
osteoarthritis is outside my scope of practice
Increased body weight is a known risk factor for the
development of lower limb osteoarthritis, and obesity is
commonly associated with progression of the condition
(Chapple, Nicholson, Baxter, & Abbott, 2011; Jacobs,
Vranceanu, Thompson, & Lattermann, 2018; Palazzo et
al., 2016; Silverwood et al., 2015). Furthermore, obesity is
associated with more negative treatment outcomes (Bliddal et
al., 2014). Weight loss is strongly recommended for people with
obesity and osteoarthritis, not only to decrease joint loading,
but also to counteract the inammatory effects of metabolically
active tissue (Chapple et al., 2011; Cicuttini & Wluka, 2016;
Jacobs et al., 2018; Palazzo et al., 2016; Silverwood et al.,
2015). Reducing body weight can signicantly lessen a person’s
likelihood of developing osteoarthritis. Critically, a reduction of
≥10% of body weight can lead to considerable reductions in
pain for people who already have the disease (Atukorala et al.,
2016). While some physiotherapists may believe that discussing
weight loss with a patient is outside their scope of practice,
physiotherapists are well placed to assist people with making
lifestyle changes that will contribute to weight loss.
Practice point myth 6: Obesity is a known modiable risk factor
for osteoarthritis, and physiotherapists should provide support
to people embarking on a weight loss programme or refer
them on to the appropriate health professional, e.g. dietician or
exercise physiologist.
Myth 7: Joint replacement surgery is inevitable
Total joint replacement (TJR) continues to be a valid treatment
option for people with advanced hip and knee osteoarthritis, but
TJR surgery is not appropriate for everyone with osteoarthritis
(Gustafsson, Ekman, Ponzer, & Heikkilä, 2010; Gwynne-Jones,
Gray, Hutton, Stout, & Abbott, 2018; Parsons, Godfrey, & Jester,
2009). Disease progression differs from person to person, and
many people may never reach the point where TJR surgery is
appropriate or necessary. Chapple et al. (2011) identied that
disease progression is multifactorial, with predictive factors
including increasing age, varus knee alignment, radiographic
changes, high body mass index and the presence of the disease
at multiple joints. Additionally, not everyone benets from
joint replacement surgery, with a substantial portion of people
continuing to report long-term joint pain after surgery (Beswick,
Wylde, Gooberman-Hill, Blom, & Dieppe, 2012; Lingard, Katz,
Wright, & Sledge, 2004). Further research is needed to identify
people most likely to benet from surgical intervention (Rice et
al., 2018).
Practice point myth 7: Physiotherapists should only consider
referring a person for orthopaedic review (TJR) after the patient
has failed an appropriate exercise programme that meets best
practice clinical guidelines (Brosseau et al., 2016; Fransen et al.,
Exercise, education and weight loss are recommended in
several clinical guidelines (Larmer et al., 2014); however these
treatment options are not consistently or routinely offered to
people with osteoarthritis in primary care (Haskins, Henderson,
& Bogduk, 2014; Hunter, 2017; Runciman et al., 2012). Within
New Zealand, the general practitioner is often the rst, and
most commonly consulted health professional for osteoarthritis
(Jolly, Bassett, O’Brien, Parkinson, & Larmer, 2017). However,
a multi-faceted approach of exercise, education and lifestyle
advice is needed to provide effective, evidence-informed care for
people with osteoarthritis. There is clearly a need for a multi-
disciplinary approach.
Primary care management of osteoarthritis in New Zealand,
at present, is fragmented and episodic, and considerable
evidence-to-practice gaps exist. Calls have been made for an
osteoarthritis model of care in New Zealand, which would
provide a framework for implementing evidence-informed care
within the New Zealand primary care system (Baldwin et al.,
2017). The term “model of care” refers to an evidence-informed
framework or policy that outlines the ideal development and
delivery of principles of care within a health system. A model of
care goes one step further than clinical guidelines by not only
outlining what the care components should be, but also how to
deliver them within a particular health system (Briggs, Towler,
Speerin, & March, 2014). An osteoarthritis model of care would
incorporate chronic care principles such as multi-disciplinary
management, collaborative care planning and self-management
In Australia, experienced physiotherapists are employed as
musculoskeletal coordinators within the New South Wales
Osteoarthritis Chronic Care Program Model of Care (Briggs et
al., 2014). These musculoskeletal coordinators perform initial
assessments of people with osteoarthritis and link these patients
to relevant health professionals within the multi-disciplinary
team as well as provide overall leadership of the programme
at each site. With expertise in exercise prescription and chronic
pain management, physiotherapists are ideally positioned to
coordinate and lead person-centred care within a New Zealand
osteoarthritis model of care (Baldwin et al., 2017); upskilling
and/or extended scope of practice roles could be required. As
an example, the New Zealand government’s Mobility Action
Programme (MAP) is supporting multi-disciplinary, community-
based teams to provide early management for people with
osteoarthritis (Ministry of Health, 2018). While the MAP
represents a positive step towards optimising osteoarthritis
management in primary care, formal policy support is needed to
upscale this programme and develop an osteoarthritis model of
care that would facilitate provision of equitable care to all New
Many myths exist about osteoarthritis, and some will limit the
potential benets that people may gain from conservative
treatment. Busting these myths will lead to a better
understanding of osteoarthritis and could contribute to better
outcomes for people living with the disease. Physiotherapists
are well placed to do this through effective education of
patients and other healthcare professionals, and by leading the
implementation of best-practice care.
1. Many myths and misconceptions exist about osteoarthritis
that can have a negative impact on how it is managed and
thus outcomes.
2. As physiotherapists, we should explore osteoarthritis
beliefs of our patients to identify and clarify potential
misconceptions about the disease.
No additional funding was obtained to support the production
of this manuscript beyond the usual academic salaries of the
The authors have no conicts of interest that merit declaration.
Dr Daniel W. O’Brien, Physiotherapy Department, School of
Clinical Sciences, Auckland University of Technology, Akoranga
Drive, Northcote, Auckland. Telephone: +64 9 921 9999 ext.
8707. Email:
Access Economics. (2018). The economic cost of arthritis in New Zealand
in 2018: Arthritis New Zealand. New Zealand: Delottes. Retrieved from
Ackerman, I. N., Bucknill, A., Page, R. S., Broughton, N. S., Roberts, C.,
Cavka, B., … Brand, C. A. (2015). The substantial personal burden
experienced by younger people with hip or knee osteoarthritis.
Osteoarthritis and Cartilage, 23(8), 1276–1284.
Ackerman, Ilana N., Kemp, J. L., Crossley, K. M., Culvenor, A., & Hinman, R.
S. (2017). Hip and knee osteoarthritis affects younger people, too. Journal
of Orthopaedic & Sports Physical Therapy, 47(2), 67–79. https://doi.
Atukorala, I., Makovey, J., Lawler, L., Messier, S. P., Bennell, K., & Hunter, D.
J. (2016). Is there a dose-response relationship between weight loss and
symptom improvement in persons with knee osteoarthritis? Arthritis Care
& Research, 68(8), 1106–1114.
Baldwin, J., Briggs, A. M., Bagg, W., & Larmer, P. J. (2017). An osteoarthritis
model of care should be a national priority for New Zealand. New Zealand
Medical Journal, 130(1467), 78–86.
Bartholdy, C., Juhl, C., Christensen, R., Lund, H., Zhang, W., & Henriksen,
M. (2017). The role of muscle strengthening in exercise therapy for
knee osteoarthritis: A systematic review and meta-regression analysis
of randomized trials. Seminars in Arthritis and Rheumatism. https://doi.
Bassett, S. F. (2015). Bridging the intention-behaviour gap with behaviour
change strategies for physiotherapy rehabilitation non-adherence. New
Zealand Journal of Physiotherapy, 43(3), 105–111.
Bennell, K. (2013). Physiotherapy management of hip osteoarthritis. Journal
of Physiotherapy, 59(3), 145–157.
Bennell, K. L., Dobson, F., & Hinman, R. S. (2014). Exercise in osteoarthritis:
Moving from prescription to adherence. Best Practice & Research Clinical
Rheumatology, 28(1), 93–117.
Bennell, K. L., & Hinman, R. S. (2011). A review of the clinical evidence for
exercise in osteoarthritis of the hip and knee. Journal of Science and
Medicine in Sport, 14(1), 4–9.
Bennell, K. L., Wrigley, T. V., Hunt, M. A., Lim, B.-W., & Hinman, R. S. (2013).
Update on the role of muscle in the genesis and management of knee
osteoarthritis. Rheumatic Diseases Clinics of North America, 39(1), 145–
Berenbaum, F. (2013). Osteoarthritis as an inammatory disease
(osteoarthritis is not osteoarthrosis!). Osteoarthritis and Cartilage, 21(1),
Beswick, A. D., Wylde, V., Gooberman-Hill, R., Blom, A., & Dieppe, P. (2012).
What proportion of patients report long-term pain after total hip or knee
replacement for osteoarthritis? A systematic review of prospective studies
in unselected patients. BMJ Open, 2(1), e000435.
Bliddal, H., Leeds, A. R., & Christensen, R. (2014). Osteoarthritis, obesity
and weight loss: evidence, hypotheses and horizons – a scoping review.
Obesity Reviews, 15(7), 578–586.
Brand, C., Ackerman, I. N., Bohensky, M. A., & Bennell, K. L. (2013). Chronic
disease management: A review of current performance across quality
of care domains and opportunities for improving osteoarthritis care.
Rheumatic Disease Clinics of North America, 39(1), 123–143. https://doi.
Brand, C., Harrison, C., Tropea, J., Hinman, R. S., Britt, H., & Bennell, K.
(2014). Management of osteoarthritis in general practice in Australia.
Arthritis Care & Research, 66(4), 551–558.
Briggs, A. M., Towler, S. C. B., Speerin, R., & March, L. M. (2014). Models of
care for musculoskeletal health in Australia: now more than ever to drive
evidence into health policy and practice. Australian Health Review, 38(4),
Brosseau, L., Wells, G. A., Pugh, A. G., Smith, C. A., Rahman, P., Àlvarez
Gallardo, I. C., … Longchamp, G. (2016). Ottawa Panel evidence-based
clinical practice guidelines for therapeutic exercise in the management
of hip osteoarthritis. Clinical Rehabilitation, 30(10), 935–946. https://doi.
Cerejo, R., Dunlop, D. D., Cahue, S., Channin, D., Song, J., & Sharma,
L. (2002). The inuence of alignment on risk of knee osteoarthritis
progression according to baseline stage of disease. Arthritis and
Rheumatism, 46(10), 2632–2636.
Chapple, C. M., Nicholson, H., Baxter, G. D., & Abbott, J. H. (2011). Patient
characteristics that predict progression of knee osteoarthritis: a systematic
review of prognostic studies. Arthritis Care & Research, 63(8), 1115–1125.
Cicuttini, F. M., & Wluka, A. E. (2016). Not just loading and age: the
dynamics of osteoarthritis, obesity and inammation. The Medical Journal
of Australia, 204(2), 47.
Cross, M., Smith, E., Hoy, D., Nolte, S., Ackerman, I., Fransen, M., …
March, L. (2014). The global burden of hip and knee osteoarthritis:
estimates from the global burden of disease 2010 study. Annals of
the Rheumatic Diseases, 73(7), 1323–1330.
Cruz-Almeida, Y., King, C. D., Goodin, B. R., Sibille, K. T., Glover, T. L., Riley, J.
L., … Fillingim, R. B. (2013). Psychological proles and pain characteristics
of older adults with knee osteoarthritis. Arthritis Care & Research, 65(11),
Da Costa, L. A., Arora, P., García-Bailo, B., Karmali, M., El-Sohemy, A., &
Badawi, A. (2012). The association between obesity, cardiometabolic
disease biomarkers, and innate immunity-related inammation in
Canadian adults. Diabetes, Metabolic Syndrome and Obesity: Targets and
Therapy, 5, 347–355.
Dean, E., & Gormsen Hansen, R. (2012). Prescribing optimal nutrition and
physical activity as rst-line interventions for best practice management of
chronic low-grade inammation associated with osteoarthritis: Evidence
synthesis. Arthritis, 2012, e560634.
Dell’Isola, A., Allan, R., Smith, S. L., Marreiros, S. S. P., & Steultjens, M.
(2016). Identication of clinical phenotypes in knee osteoarthritis: A
systematic review of the literature. BMC Musculoskeletal Disorders, 17,
Deveza, L. A., Melo, L., Yamato, T. P., Mills, K., Ravi, V., & Hunter, D. J.
(2017). Knee osteoarthritis phenotypes and their relevance for outcomes:
A systematic review. Osteoarthritis and Cartilage.
Felson, D. T., Niu, J., Neogi, T., Goggins, J., Nevitt, M. C., Roemer, F.,
… MOST Investigators Group. (2016). Synovitis and the risk of knee
osteoarthritis: the MOST Study. Osteoarthritis and Cartilage, 24(3), 458–
Fitzgerald, G. K., Fritz, J. M., Childs, J. D., Brennan, G. P., Talisa, V., Gil, A.,
… Abbott, J. H. (2016). Exercise, manual therapy, and use of booster
sessions in physical therapy for knee osteoarthritis: A multi-center,
factorial randomized clinical trial. Osteoarthritis and Cartilage. https://doi.
Fransen, M., McConnell, S., Harmer, A. R., Van der Esch, M., Simic, M.,
& Bennell, K. L. (2015). Exercise for osteoarthritis of the knee. The
Cochrane Database of Systematic Reviews, 1, CD004376. https://doi.
Gustafsson, B. Å., Ekman, S.-L., Ponzer, S., & Heikkilä, K. (2010). The hip and
knee replacement operation: an extensive life event. Scandinavian Journal
of Caring Sciences, 24(4), 663–670.
Gwynne-Jones, D. P., Gray, A. R., Hutton, L. R., Stout, K. M., & Abbott, J. H.
(2018). Outcomes and factors inuencing response to an individualized
multidisciplinary chronic disease management program for hip and knee
osteoarthritis. The Journal of Arthroplasty.
Hall, M., Migay, A.-M., Persad, T., Smith, J., Yoshida, K., Kennedy, D., &
Pagura, S. (2008). Individuals’ experience of living with osteoarthritis of the
knee and perceptions of total knee arthroplasty. Physiotherapy Theory and
Practice, 24(3), 167–181.
Haskins, R., Henderson, J. M., & Bogduk, N. (2014). Health professional
consultation and use of conservative management strategies in patients
with knee or hip osteoarthritis awaiting orthopaedic consultation.
Australian Journal of Primary Health, 20(3), 305–310. https://doi.
Hawker, G., French, M. R., Waugh, E. J., Gignac, M. a. M., Cheung, C.,
& Murray, B. J. (2010). The multidimensionality of sleep quality and
its relationship to fatigue in older adults with painful osteoarthritis.
Osteoarthritis and Cartilage, 18(11), 1365–1371.
Hawker, G., Gignac, M. A. M., Badley, E., Davis, A. M., French, M. R., Li, Y.,
… Lou, W. (2011). A longitudinal study to explain the pain-depression
link in older adults with osteoarthritis. Arthritis Care & Research, 63(10),
Hochberg, M. C., Altman, R. D., April, K. T., Benkhalti, M., Guyatt, G.,
McGowan, J., … American College of Rheumatology. (2012). American
College of Rheumatology 2012 recommendations for the use of
nonpharmacologic and pharmacologic therapies in osteoarthritis of the
hand, hip, and knee. Arthritis Care & Research, 64(4), 465–474. https://
Hochberg, M. C., Silman, A., Smolen, J., Weinblatt, M., & Weisman, M.
(2015). Rheumatology (4thed., Vols 1–2). Philapelphia, USA: Elsevier.
Hunter, D. J. (2011). Lower extremity osteoarthritis management needs a
paradigm shift. British Journal of Sports Medicine, 45(4), 283–288. https://
Hunter, D. J. (2017). Osteoarthritis management: Time to change the deck.
The Journal of Orthopaedic and Sports Physical Therapy, 47(6), 370–372.
Hunter, D. J., & Lo, G. H. (2009). The management of osteoarthritis: An
overview and call to appropriate conservative treatment. Medical Clinics,
93(1), 127–143.
Hunter, D. J., Neogi, T., & Hochberg, M. C. (2011). Quality of osteoarthritis
management and the need for reform in the US. Arthritis Care & Research,
63(1), 31–38.
Jacobs, C. A., Vranceanu, A.-M., Thompson, K. L., & Lattermann, C.
(2018). Rapid progression of knee pain and osteoarthritis biomarkers
greatest for patients with combined obesity and depression: Data from
the osteoarthritis initiative. Cartilage, 1947603518777577. https://doi.
Jacobsen, S., & Sonne-Holm, S. (2005). Hip dysplasia: a signicant risk
factor for the development of hip osteoarthritis. A cross-sectional survey.
Rheumatology (Oxford, England), 44(2), 211–218.
Jolly, J., Bassett, S. F., O’Brien, D., Parkinson, C., & Larmer, P. J. (2017). An
exploration of the sequence and nature of treatment options available
to people living with osteoarthritis of the hip and/or knee within a New
Zealand context. New Zealand Journal of Physiotherapy, 45(2), 90–95.
Jordan, J. M., Helmick, C. G., Renner, J. B., Luta, G., Dragomir, A. D.,
Woodard, J., … Hochberg, M. C. (2007). Prevalence of knee symptoms
and radiographic and symptomatic knee osteoarthritis in African
Americans and Caucasians: The Johnston County Osteoarthritis Project.
The Journal of Rheumatology, 34(1), 172–180.
Kujala, U. M. (2009). Evidence on the effects of exercise therapy in the
treatment of chronic disease. British Journal of Sports Medicine, 43(8),
Larmer, P. J., Reay, N. D., Aubert, E. R., & Kersten, P. (2014). Systematic
review of guidelines for the physical management of osteoarthritis.
Archives of Physical Medicine and Rehabilitation, 95(2), 375–389. https://
Lingard, E. A., Katz, J. N., Wright, E. A., & Sledge, C. B. (2004). Predicting
the outcome of total knee arthroplasty. Journal of Bone and Joint Surgery
(American), 86(10), 2179.
Loew, L., Brosseau, L., Wells, G. A., Tugwell, P., Kenny, G. P., Reid, R., …
Ottawa Panel. (2012). Ottawa panel evidence-based clinical practice
guidelines for aerobic walking programs in the management of
osteoarthritis. Archives of Physical Medicine and Rehabilitation, 93(7),
McAlindon, T. E., Bannuru, R. R., Sullivan, M. C., Arden, N. K., Berenbaum,
F., Bierma-Zeinstra, S. M., … Underwood, M. (2014). OARSI guidelines for
the non-surgical management of knee osteoarthritis. Osteoarthritis and
Cartilage, 22(3), 363–388.
Mease, P. J., Hanna, S., Frakes, E. P., & Altman, R. D. (2011). Pain mechanisms
in osteoarthritis: Understanding the role of central pain and current
approaches to its treatment. The Journal of Rheumatology, 38(8), 1546–
Merashly, M., & Uthman, I. (2012). Management of knee osteoarthritis: An
evidence-based review of treatment options. Le Journal Médical Libanais.
The Lebanese Medical Journal, 60(4), 237–242.
Mills, K., Hübscher, M., O’Leary, H., & Moloney, N. (2019). Current concepts
in joint pain in knee osteoarthritis. Schmerz (Berlin, Germany), 33(1),
Ministry of Health. (2018). The Mobility Action Programme. Wellington, New
Zealand: Ministry of Health. Retrieved from
National Institue for Health and Care Excellence. (2015). Osteoarthritis NICE
Guidelines (National Standard). London: National Institute of Health and
Care Excellence. Retrieved from
O’Brien, D., Bassett, S., & McNair, P. J. (2013). The effect of action and coping
plans on exercise adherence in people with osteoarthritis. New Zealand
Journal of Physiotherapy, 41(2), 49–57.
Palazzo, C., Nguyen, C., Lefevre-Colau, M.-M., Rannou, F., & Poiraudeau,
S. (2016). Risk factors and burden of osteoarthritis. Annals of Physical
and Rehabilitation Medicine, 59(3), 134–138.
Palmer, K. T. (2012). Occupational activities and osteoarthritis of the knee.
British Medical Bulletin, 102, 147–170.
Parsons, G. E., Godfrey, H., & Jester, R. F. (2009). Living with severe
osteoarthritis while awaiting hip and knee joint replacement surgery.
Musculoskeletal Care, 7(2), 121–135.
Phan, C. M., Link, T. M., Blumenkrantz, G., Dunn, T. C., Ries, M. D.,
Steinbach, L. S., & Majumdar, S. (2005). MR imaging ndings in the
follow-up of patients with different stages of knee osteoarthritis and the
correlation with clinical symptoms. European Radiology, 16(3), 608–618.
Pinto, D., Robertson, M. C., Abbott, J. H., Hansen, P., & Campbell, A. J.
(2013). Manual therapy, exercise therapy, or both, in addition to usual
care, for osteoarthritis of the hip or knee. 2: Economic evaluation
alongside a randomized controlled trial. Osteoarthritis and Cartilage,
21(10), 1504–1513.
Piva, S. R., Susko, A. M., Khoja, S. S., Josbeno, D. A., Fitzgerald, G. K.,
& Toledo, F. G. S. (2015). Links between osteoarthritis and diabetes:
Implications for management from a physical activity perspective.
Clinics in Geriatric Medicine, 31(1), 67–87.
Poitras, S., Rossignol, M., Avouac, J., Avouac, B., Cedraschi, C.,
Nordin, M., … Hilliquin, P. (2010). Management recommendations
for knee osteoarthritis: how usable are they? Joint, Bone, Spine:
Revue Du Rhumatisme, 77(5), 458–465.
Rice, D. A., Kluger, M., McNair, P. J., Lewis, G. N., Somogyi, A. A.,
Borotkanics, R., … Walker, M. (2018). Persistent postoperative pain after
total knee arthroplasty: a prospective cohort study of potential risk factors.
British Journal of Anaesthesia, 121(4), 804–812.
Rosemann, T., Laux, G., Szecsenyi, J., & Grol, R. (2008). The Chronic Care
Model: congruency and predictors among primary care patients with
osteoarthritis. Quality and Safety in Health Care, 17(6), 442–446. https://
Runciman, W. B., Hunt, T. D., Hannaford, N. A., Hibbert, P. D., Westbrook,
J. I., Coiera, E. W., … Braithwaite, J. (2012). CareTrack: assessing the
appropriateness of health care delivery in Australia. The Medical Journal of
Australia, 197(2), 100–105.
Sharma, L., Song, J., Dunlop, D., Felson, D., Lewis, C. E., Segal, N., … Nevitt,
M. (2010). Varus and valgus alignment and incident and progressive knee
osteoarthritis. Annals of the Rheumatic Diseases, 69(11), 1940–1945.
Silverwood, V., Blagojevic-Bucknall, M., Jinks, C., Jordan, J. L., Protheroe,
J., & Jordan, K. P. (2015). Current evidence on risk factors for knee
osteoarthritis in older adults: A systematic review and meta-analysis.
Osteoarthritis and Cartilage, 23(4), 507–515.
Skou, S. T., Pedersen, B. K., Abbott, J. H., Patterson, B., & Barton, C. (2018).
Physical activity and exercise therapy benet more than just symptoms
and impairments in people with hip and knee ossteoarthritis. The Journal
of Orthopaedic and Sports Physical Therapy, 48(6), 439–447. https://doi.
Van Manen, M. D., Nace, J., & Mont, M. A. (2012). Management of primary
knee osteoarthritis and indications for total knee arthroplasty for general
practitioners. The Journal of the American Osteopathic Association,
112(11), 709–715.
Zhang, W., Moskowitz, R. W., Nuki, G., Abramson, S., Altman, R. D., Arden,
N., … Tugwell, P. (2008). OARSI recommendations for the management
of hip and knee osteoarthritis, Part II: OARSI evidence-based, expert
consensus guidelines. Osteoarthritis and Cartilage, 16(2), 137–162. https://
... First, X-ray is still considered a critical diagnostic tool by some clinicians, despite current contradictory evidence and recommendations that suggest that imaging is unnecessary (National Institute for Health and Care Excellence, 2015). Imaging correlates poorly with symptoms and, in some cases, is harmful because it reinforces a purely mechanical view of the disease (Bunzli et al., 2019;O'Brien et al., 2019). Second, surgical joint replacement is common and effective for reducing pain (Hochberg et al., 2015;Leskinen et al., 2012). ...
... Furthermore, 64% of participants indicated they usually referred people with OA to an orthopaedic surgeon. The reason for these findings is not apparent, but the results may reflect a perception that joint replacement surgery is inevitable for people with OA or the limited state-funded conservative treatment services available to people with OA in New Zealand (Baldwin et al., 2017;Bunzli et al., 2019;O'Brien et al., 2019). ...
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Physiotherapists’ and general practitioners’ (GPs) treatment knowledge affects the management of people with knee osteoarthritis (OA), but little is known about the OA referral decisions and treatment knowledge of these clinicians in New Zealand. Data were collected from New Zealand registered physiotherapists and GPs (n = 272) using an online vignette-based questionnaire. Approximately two-thirds (63%, n = 172) of participants stated they would likely refer the hypothetical patient with knee OA to another profession. Participants indicated they would refer the woman between the two professions (73%, n = 57 GPs would refer to a physiotherapist; 47%, n = 92 physiotherapists would refer to a GP). However, few participants indicated they would refer the woman to other health professionals (such as 19%, n = 52 would refer to a dietitian). The majority of participants reported they would recommend education (98%, n = 267), therapeutic exercises (92%, n = 251) and weight-loss advice (87%, n = 237) as treatments for knee OA. These results indicate that first-line knee OA treatment knowledge of New Zealand GPs and physiotherapists are generally in keeping within international guidelines. However, promoting interprofessional collaboration with other health professions, such as dietetics, and providing education regarding treatments not recommended for OA is needed to meet all first-line treatment recommendations.
... Symptoms in the affected joint/s such as stiffness, pain and instability, tend to worsen in severity over time [3]. These symptoms can lead to functional limitations, especially considering mobility, as well as decrease of independence in activities of daily living [3][4][5]. After a certain point, conservative interventions are unsuccessful in restricting disease progression of osteoarthritis [5]. ...
... These symptoms can lead to functional limitations, especially considering mobility, as well as decrease of independence in activities of daily living [3][4][5]. After a certain point, conservative interventions are unsuccessful in restricting disease progression of osteoarthritis [5]. Therefore, in order to improve signs and symptoms of osteoarthritis, the most common orthopedic procedures are elective primary total hip and knee arthroplasty (THA, TKA). ...
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Introduction: There are many factors influencing the outcome after total joint arthroplasty (TJA). In particular, patient-related factors such as age, gender, ASA (American Society of Anesthesiologists), or preoperative anxiety/depression have become increasingly important. The aim of this study was to examine the association of these parameters with 1-year postoperative outcomes after total knee and total hip arthroplasty (TKA, THA). Methods: A retrospective cohort of 5447 TJA patients was evaluated by pre- and postoperative analysis of EQ-5D, EQ-VAS and WOMAC Score. Furthermore, major focus was put on the association between age, gender, ASA, preoperative anxiety/depression and outcome parameters. Results: 53.3% (2903/5447) of all patients were identified with anxiety/depression at time of surgery. In the analysis, patients without anxiety/depression showed statistically significantly (p < 0.05) better EQ-5D, EQ-VAS and WOMAC scores. In addition, patients with ASA 2 or 3 and age over 70 years showed statistically significantly (p < 0.01) worse EQ-5D and WOMAC scores. Gender did not influence the postoperative EQ-5D and WOMAC results, but men had significantly better EQ-VAS scores than women in this study. Conclusion: Preoperative anxiety/depression symptoms show worse clinical outcomes 1 year postoperatively after TJA. Other outcome-influencing factors are higher age and ASA 2 or 3. In the future, such patients should be identified, and as far as applicable, a treatment of anxiety/depression or comorbidities should be implemented preoperatively of the surgical procedure to improve clinical outcomes.
... Symptoms may include severe pain, stiffness, and instability in the affected joint/s (Stark and Price, 2019;Törmälehto et al., 2019). Because there is no known cure and symptoms tend to worsen in severity over time, osteoarthritis can have a progressively debilitating impact on an individual's health and functioning (Hunter and Bierma-Zeinstra, 2019;Törmälehto et al., 2019), particularly when conservative management interventions are unsuccessful in restricting disease progression (Jones et al., 2007;O'Brien et al., 2019). Patients with end-stage osteoarthritis experience considerable pain, as well as functional limitations in relation to mobility, activities of daily living, independence, and occupational and social participation (Neogi, 2013;O'Brien et al., 2019;Törmälehto et al., 2019). ...
... Because there is no known cure and symptoms tend to worsen in severity over time, osteoarthritis can have a progressively debilitating impact on an individual's health and functioning (Hunter and Bierma-Zeinstra, 2019;Törmälehto et al., 2019), particularly when conservative management interventions are unsuccessful in restricting disease progression (Jones et al., 2007;O'Brien et al., 2019). Patients with end-stage osteoarthritis experience considerable pain, as well as functional limitations in relation to mobility, activities of daily living, independence, and occupational and social participation (Neogi, 2013;O'Brien et al., 2019;Törmälehto et al., 2019). Symptoms can lead to disrupted sleep and fatigue (Sasaki et al., 2014a), and reliance on a caregiver (Hunter et al., 2014). ...
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Total knee arthroplasty (TKA) is a commonly implemented elective surgical treatment for end-stage osteoarthritis of the knee, demonstrating high success rates when assessed by objective medical outcomes. However, a considerable proportion of TKA patients report significant dissatisfaction postoperatively, related to enduring pain, functional limitations, and diminished quality of life. In this conceptual analysis, we highlight the importance of assessing patient-centered outcomes routinely in clinical practice, as these measures provide important information regarding whether surgery and postoperative rehabilitation interventions have effectively remediated patients’ real-world “quality of life” experiences. We propose a novel precision medicine approach to improving patient-centered TKA outcomes through the development of a multivariate machine-learning model. The primary aim of this model is to predict individual postoperative recovery trajectories. Uniquely, this model will be developed using an interdisciplinary methodology involving non-linear analysis of the unique contributions of a range of preoperative risk and resilience factors to patient-centered TKA outcomes. Of particular importance to the model’s predictive power is the inclusion of a comprehensive assessment of modifiable psychological risk and resilience factors that have demonstrated relationships with TKA and other conditions in some studies. Despite the potential for patient psychological factors to limit recovery, they are typically not routinely assessed preoperatively in this patient group, and thus can be overlooked in rehabilitative referral and intervention decision-making. This represents a research-to-practice gap that may contribute to adverse patient-centered outcomes. Incorporating psychological risk and resilience factors into a multivariate prediction model could improve the detection of patients at risk of sub-optimal outcomes following TKA. This could provide surgeons and rehabilitation providers with a simplified tool to inform postoperative referral and intervention decision-making related to a range of interdisciplinary domains outside their usual purview. The proposed approach could facilitate the development and provision of more targeted rehabilitative interventions on the basis of identified individual needs. The roles of several modifiable psychological risk and resilience factors in recovery are summarized, and intervention options are briefly presented. While focusing on rehabilitation following TKA, we advocate for the broader utilization of multivariate prediction models to inform individually tailored interventions targeting a range of health conditions.
... Severe pain, stiffness, and instability in the afflicted joint(s) are possible symptoms [3,4]. Because there is no known cure and symptoms tend to worsen over time, osteoarthritis can have a debilitating effect on a person's health and functioning [2,4], especially when conservative management fails to slow disease progression [5,6]. ...
Introduction: Total knee replacement (TKR) is commonly carried out in patients with advanced osteoarthritis to reduce pain and increase. The study aimed to investigate functional outcomes after Total Knee Replacement (TKR) among orthopedic patients at Babcock University Teaching Hospital, Ogun, South West, Nigeria. Methods: Registry data of patients who underwent TKR between January 1st, 2021 to December 30th, 2021 were collected and retrospectively reviewed. Sociodemographic and anthropometric data together with the Oxford Knee Score (OKS) were collated both preoperatively and postoperatively (12 weeks after surgery). Results: There was significant increase in the OKS postoperatively, which was statistically significant. There was significant difference between pre-operative OKS and post-operative OKS (p=0.0049). Conclusion: Overall, there was clinically significant change in the OKS after surgery. This implies greater reduction in pain and increase functional outcomes.
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Background: Persistent postoperative pain (PPP) is common after total knee arthroplasty (TKA). The primary aim of this prospective cohort study was to identify important predictors of moderate to severe PPP 6 and 12 months after TKA. Methods: Consenting patients (n=300) undergoing primary unilateral TKA attended a preoperative session to collect clinical information (age, gender, BMI, preoperative knee pain, comorbid pain, likely neuropathic pain) and psychological variables (depression, anxiety, catastrophising, expected pain). Quantitative sensory testing (pressure pain thresholds, temporal summation, conditioned pain modulation) was performed, and blood samples were obtained for subsequent genotyping of OPRM1 and COMT. Acute postoperative pain was measured at rest and during movement. Surgical factors (surgery time, patella resurfacing, anaesthetic type) were collected after operation. Follow-up questionnaires were sent 6 and 12 months after surgery. Multivariate logistic regression was used to identify predictors of PPP. Results: The prevalence of moderate to severe PPP was 21% (n=60) and 16% (n=45) 6 and 12 months after surgery, with 55% (n=33) and 60% (n=31) of PPP likely neuropathic in nature. At 6 months, a combination of preoperative pain intensity, expected pain, trait anxiety, and temporal summation (Akaike information criterion, 309.9; area under receiver operating characteristic (ROC) curve, 0.70) was able to correctly classify 66% of patients into moderate to severe PPP and no to mild PPP groups. At 12 months, preoperative pain intensity, expected pain, and trait anxiety (Akaike information criterion, 286.8; area under ROC curve, 0.66) correctly classified 66% of patients. Conclusions: Findings from this study highlight several factors that may be targeted in future intervention studies to reduce the development of PPP. Trial registry number: ACTRN12612001089820.
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Objective: To compare the progression of biochemical biomarkers of osteoarthritis (OA), knee pain, and function between nonobese patients (NON), obese patients without depression (OBESE), and obese patients with comorbid depression (O + D). Design: Utilizing the FNIH OA Biomarkers Consortium dataset, we categorized knee OA patients into NON, OBESE, and O + D groups based on body mass index and Center for Epidemiological Studies-Depression (CES-D) scores. Subjective symptoms (Knee injury and Osteoarthritis Outcome Score Quality of Life subscale (KOOS QOL), Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) Pain and Physical Function scores, and the Short Form-12 (SF-12) Physical Component Score [PCS]) and objective measures of cartilage degradation and bone remodeling (urinary CTXII and CTXIα) were compared among groups at baseline and 2-year follow-up. Results: Of the 600 patients, 282 (47%) were NON, 285 (47.5%) OBESE, and 33 (5.5%) O + D. The O + D group had significantly worse pain and function both at baseline and 2-year follow-up (P < 0.001 for all comparisons) as evidenced by self-reported measures on KOOS QOL, WOMAC Pain, WOMAC Physical Function, and SF-12 PCS. The O + D group also demonstrated significant increases in CTXII (P = 0.01) and CTXIα (P = 0.005), whereas the NON and OBESE groups did not. Conclusions: The combination of inferior knee pain, physical function, and significantly greater increases in biomarkers of cartilage degradation and bony remodelling suggest a more rapid progression for obese OA patients with comorbid depression. The link between systemic disease, inflammatory burden, and progressive cartilage degradation is in line with increasing concerns about a degenerative synovial environment in early osteoarthritic knees that progress to treatment failure with biologic restoration procedures.
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Joint pain attributable to osteoarthritis (OA) is complex and influenced by a myriad of factors beyond local joint pathology. Current practice continues to predominantly adopt a biomedical approach to OA despite emerging evidence of the importance of a more holistic approach. This paper will summarise evidence for the presence of multidimensional pain profiles in knee joint pain and the presence of subgroups characterized by systemic features such as psychological distress, high comorbidity load or sensitisation of the nervous system. These factors have the potential to influence patient outcomes making them relevant for clinicians and highlighting the necessity of a broader multifactorial approach to assessment and treatment. This review describes the current state of the evidence for treatments of people with knee OA-related pain, including those receiving strong recommendations from current clinical guidelines, namely exercise, weight loss, self-management advice and pharmacological approaches. Other pain-modulating treatment options are emerging such as sleep and psychological interventions, pain education and multisensory retraining. The evidence and rationale for these newer therapeutic approaches is discussed. Finally, this review will highlight some of the limitations of current international guidelines for the management of OA and make recommendations for future research.
The aim of this study was to explore the sequence and nature of treatment options available to people living with osteoarthritis of the hip and/or knee in New Zealand. Twenty-three people living with hip and/or knee joint OA participated in face-to-face interviews about their experiences of OA treatments they were offered and received. All data were analysed thematically. Data analysis led to the identification of three themes, which were, general practitioner (GP) as initial contact; lack of a clear treatment pathway; inconsistent provision of information. Theme 1 highlighted that participants utilised their GP as their initial and primary health care provider for OA management advice. Theme 2 explored participants’ reports of exploring a variety of treatment options for their hip and/or knee joint OA, establishing that there is no clearly defined treatment pathway. Theme 3 identified notions regarding participant education about OA. Analysis indicated that people living with OA are looking for consistent advice and a clear management pathway. The GP was the first health professional that most participants had contacted about their OA, however following this consultation there was no clear identifiable management pathway.
Synopsis Hip and knee osteoarthritis (OA) are among the leading causes of global disability, highlighting the need for early, targeted, and effective treatments. The benefits on symptoms and impairments of exercise therapy in people with hip and knee OA are substantial and supported by high-quality evidence, underlining that it should be part of first line treatment offered to all people with hip and knee OA in clinical practice. Furthermore, unlike other treatments for OA such as analgesia and surgery, exercise therapy is not associated with risk of serious harm. Promoting and helping people with OA become more physically active alongside participating in structured exercise therapy targeting symptoms and impairments is crucial considering the majority of people with hip and knee OA do not meet physical activity recommendations. OA is associated with a range of chronic comorbidities, including type 2 diabetes, cardiovascular disease, and dementia, all of which are associated with chronic low-grade inflammation. Physical activity and exercise therapy not only improves symptoms and impairments of OA, it is also effective as prevention of at least 35 chronic conditions and as treatment of at least 26 chronic conditions with one of the potential working mechanisms being exercise induced anti-inflammatory effects. Patient education may be crucial to ensure long-term adherence and sustained positive effects on symptoms, impairments, physical activity levels and comorbidities. J Orthop Sports Phys Ther, Epub 18 Apr 2018. doi:10.2519/jospt.2018.7877.
Introduction/Aims of study To investigate the effectiveness of, and factors associated with, response to a chronic disease management programme for patients with hip and knee osteoarthritis (OA). Methods Over a two year period (2012-14) 218 patients (97 hip OA; 121 knee OA) were managed with an individualised programme of interventions that could include education, physiotherapy, orthotics, occupational therapy or dietitian referral. Changes in Oxford hip or knee score (OHS, OKS) and Short form 12 (SF12) Physical and Mental Component Score (PCS, MCS) were analysed by joint affected, both unadjusted and gender and age adjusted. A further analysis also adjusted for BMI. Results At mean 12 months follow up patients with knee OA had a statistically significant improvement in OKS and PCS, while patients with hip OA had a statistically significant deterioration in all 3 scores. There was evidence that these changes differed between joints for Oxford and PCS scores. Greater age was associated with worse outcomes for Oxford scores. Higher BMI was associated with worse outcomes for Oxford and PCS scores. Patients with hip OA (35%) were more likely to deteriorate to a clinically significant extent (5 points) for Oxford scores than patients with knee OA. Gender was not associated with outcomes. Patients with hip OA (54%) were more likely than those with knee OA (24%) to have subsequently had surgery (p<0.001). Conclusions Patients with knee OA were more likely to improve with a chronic disease management plan than patients with hip OA and efforts should be directed to them.
Osteoarthritis is highly prevalent, disabling and costly to the person and the community. The burden of this chronic condition is predicted to increase dramatically over the coming decades. Healthcare spending on osteoarthritis is unsustainable and action is needed to improve care delivery. At present, there is an over-emphasis on surgical and pharmacological interventions, despite evidence supporting conservative treatments such as exercise, weight loss and education. While clinical guidelines provide recommendations regarding best practice (ie, what to do), they fail to address how to operationalise these recommendations into clinical practice. Models of care (MoCs) can help bridge the evidence-practice gap by outlining evidence-informed interventions as well as how to implement them within a local system. However, New Zealand has no osteoarthritis MoC. The Mobility Action Programme, funded by the Ministry of Health, is delivering evidence-informed, multi-disciplinary care for osteoarthritis through local initiatives. Although the programme remains under evaluation it presents an opportunity to inform development of a national osteoarthritis MoC for New Zealand. A policy framework, such as a MoC, is needed to scale up successful programs and deliver best practice care nationwide. Ultimately, addressing the burden of osteoarthritis will require system-wide approaches involving public policy responses to target primary prevention.
Objective: To systematically review the literature for studies investigating knee osteoarthritis (OA) phenotypes to examine what OA characteristics are relevant for phenotyping. Methods: A comprehensive search was performed in Medline, EMBASE, Web of Sciences, CINAHL, and Scopus databases from inception to September 2016. Inclusion was limited to observational studies of individuals with symptomatic knee OA that identified phenotypes based on any OA characteristics and assessed their association with clinically important outcomes. A descriptive synthesis of the data was performed. Results: Of the 2,777 citations retrieved, 34 studies were included. Clinical phenotypes were investigated most frequently, followed by laboratory, imaging and aetiologic phenotypes. Eight studies defined subgroups based on outcome trajectories (pain, function and radiographic progression trajectories). Most studies used a single patient or disease characteristic to identify patients subgroups while five included characteristics from multiple domains. We found evidence from multiple studies suggesting that pain sensitization, psychological distress, radiographic severity, body mass index, muscle strength, inflammation and comorbidities are associated with clinically distinct phenotypes. Gender, obesity and other metabolic abnormalities, the pattern of cartilage damage, and inflammation may be implicated in delineating distinct structural phenotypes. Only a few studies investigated the external validity of the phenotypes or their prospective validity using longitudinal outcomes. Conclusions: There is marked heterogeneity in the data selected by the studies investigating knee OA phenotypes. We identified the phenotypic characteristics that can be considered for a comprehensive phenotype classification in future studies. A framework for the investigation of phenotypes could be useful for future studies. Protocol registration: PROSPERO CRD42016036220.
This Viewpoint highlights the shortcomings of existing osteoarthritis (OA) clinical practices and emphasizes the opportunity that can come about by virtue of adherence to appropriate management. In an effort to emphasize optimism, there are huge missed opportunities with existing efficacious treatments and tremendous developments that are currently going on that will positively influence future care. How we respond to that opportunity will not only impact the individuals disabled by the disease but also make a massive difference to our society through reducing underemployment and health care waste. J Orthop Sports Phys Ther 2017;47(6):370–372. doi:10.2519/jospt.2017.0605
Objectives: To analyze if exercise interventions for patients with knee osteoarthritis (OA) following the American College of Sports Medicine (ACSM) definition of muscle strength training differs from other types of exercise, and to analyze associations between changes in muscle strength, pain, and disability. Methods: A systematic search in 5 electronic databases was performed to identify randomized controlled trials comparing exercise interventions with no intervention in knee OA, and reporting changes in muscle strength and in pain or disability assessed as standardized mean differences (SMD) with 95% confidence intervals (95% CI). Interventions were categorized as ACSM interventions or not-ACSM interventions and compared using stratified random effects meta-analysis models. Associations between knee extensor strength gain and changes in pain/disability were assessed using meta-regression analyses. Results: The 45 eligible trials with 4699 participants and 56 comparisons (22 ACSM interventions) were included in this analysis. A statistically significant difference favoring the ACSM interventions with respect to knee extensor strength was found [SMD difference: 0.448 (95% CI: 0.091-0.805)]. No differences were observed regarding effects on pain and disability. The meta-regressions indicated that increases in knee extensor strength of 30-40% would be necessary for a likely concomitant beneficial effect on pain and disability, respectively. Conclusion: Exercise interventions following the ACSM criteria for strength training provide superior outcomes in knee extensor strength but not in pain or disability. An increase of less than 30% in knee extensor strength is not likely to be clinically beneficial in terms of changes in pain and disability (PROSPERO: CRD42014015344).